Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Effective date: [date to be set by counsel]

This notice is from Today’s Dental (“we”, “us” or “our”), the dental practice of Dr. Ayaba Guiste, DDS, at 604 N Willis Ave, Livingston, TX 77351. It covers Dr. Guiste and everyone who works for us when they care for you or handle your information for our practice. In this notice, “health information” means information that identifies you and is about your health, your care or payment for your care. Examples are your dental records, x-rays and photos, health history, and billing and insurance details.

Federal law (HIPAA) and Texas law both protect your health information. Where Texas law protects it more, we follow Texas law. The main Texas protections are described under Extra protections under Texas law.

If you have questions about this notice, call our privacy officer at (936) 327-2151, or write to our privacy officer at Today’s Dental, 604 N Willis Ave, Livingston, TX 77351.

Your rights

You have these rights about your health information. To use any of them, ask at the front desk, call our privacy officer at (936) 327-2151, or write to us at the address above. We may ask you to make your request in writing and to show ID.

Get a copy of your records

You can ask to see or get a copy of your dental and billing records and other health information we have about you, on paper or electronically.
We will give you a copy, or a summary if you agree to one, within 30 days of your request. If you ask in writing for an electronic copy of records we keep electronically, we will give it to you within 15 business days when our records system can produce it, as Texas law requires.
If you ask for an electronic copy, we will give it to you in the form and format you ask for, if we can readily produce it that way. If we cannot, we will work with you to agree on another electronic format you can read.
You can ask us to send copies of your dental records to another dentist who is treating you or will treat you.
You can also ask us to send an electronic copy of the records in our electronic health record directly to another person you choose. This request must be in writing, signed by you, and say who should receive the copy and where to send it.
To have us send any other copy to someone else, for example paper copies to a lawyer or a relative, sign a written permission that says what information to send, who should receive it and why.
For copies we give or send to you, we may charge a reasonable, cost-based fee, within the limits that federal and Texas law set. For copies we send to someone else at your request, we may charge a fee within the limits that Texas law sets. We will tell you the fee before we make the copies. Texas rules do not allow us to hold back copies of your records because you owe us for past care.
If we say no to any part of your request, we will tell you why in writing. We will also tell you if you can ask to have that decision reviewed.

Ask us to correct your records

You can ask us to correct health information about you that you think is incorrect or incomplete. Tell us why you think it should change.
We will answer within 60 days. If we need more time, we will tell you why in writing, and we will take no more than 30 more days. We may say no, but if we do, we will tell you why in writing.
If we say no, you can give us a written statement of disagreement, and we will keep it with your records.

Ask us to contact you in a certain way

You can ask us to contact you in a specific way, for example only at a certain phone number, or by mail to a different address.
We will say yes to all reasonable requests, and we will not ask you why.

You can ask us not to use or share certain health information for treatment, payment or running our practice. You can also ask us not to share it with family or friends involved in your care. We do not have to agree, and we may say no if it would affect your care. If we agree, we will follow the limit unless the information is needed to give you emergency treatment.
If you pay in full, out of pocket, for a service or health care item, you can ask us not to share information about it with your dental or health plan for payment or for running our practice. We will say yes unless a law requires us to share that information.

Get a list of who we have shared your information with

You can ask for a list (an accounting) of the times we shared your health information in the six years before your request. The list shows who we shared it with and why.
The list will include every time we shared your information except for treatment, payment and running our practice, and certain other times, such as sharing you asked us to do. We will answer within 60 days, or tell you in writing if we need up to 30 more days.
The first list in any 12 months is free. If you ask for another within the same 12 months, we may charge a reasonable, cost-based fee. We will tell you the fee first, so you can change or withdraw your request.

Get a copy of this notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive it electronically. Ask at the front desk, or call us and we will mail you one.
This notice is also posted in our office and on our website at todaysdentaltx.com/notice-of-privacy-practices/.

Choose someone to act for you

If you have given someone a medical power of attorney, or if someone is your legal guardian, that person can use your rights and make choices about your health information. We will make sure the person has this authority before we act on their request.
For a patient under 18, a parent, managing conservator or guardian usually acts for the child. Under Texas law, a parent who has been appointed a conservator of the child has the right to see the child’s dental records unless a court order limits that right. Please give us a copy of any court order that affects a parent’s rights.
In the few situations where Texas law allows a person under 18 to consent to their own dental care, that person usually makes the choices about the information from that care. Texas law still allows us to tell a parent, managing conservator or guardian about treatment the young person received or needs.
After a patient’s death, the patient’s personal representative, such as the executor of the estate, can make these choices.

File a complaint if you feel your rights are violated

You can complain to us, to the U.S. Department of Health and Human Services, or to the State of Texas. See Contact and complaints below.

Your choices

For some health information, you can tell us your choices about what we share. If you have a clear preference about how we share your information in the situations below, tell us, and we will follow your instructions.

Family, friends and others involved in your care. You can tell us to share information with a family member, close friend or other person you name who is involved in your care or helps pay for it, for example someone who comes to your appointment with you or drives you home.
Disaster relief. You can tell us to share information with a disaster relief organization so it can help let your family know where you are and how you are doing.

Texas law gives your dental records extra protection, so we will usually ask you to give us these instructions in writing.

If you are not able to tell us your choice, for example in a medical emergency, we may share information with the emergency medical personnel caring for you. If we believe it is more likely than not that you or someone else will be physically hurt very soon, we may also share information with medical or law enforcement personnel to help prevent it.

To treat you

We use your health information to care for you, and we share it with other dentists and dental professionals who are helping to diagnose or treat you. For example, if we refer you to a dental specialist, we send the specialist your x-rays and the findings they need. When a dental laboratory makes your crown, bridge or denture, we send it the impressions and instructions it needs.

With your written consent, we also share information with your physician or your child’s doctor when we need to coordinate your care.

To bill for your care

We use and share your health information to bill and get payment for your care. For example, when you ask us to file a claim with your dental plan, we send the plan the information it needs to pay for your care, such as the treatment we provided and x-rays when it asks for them. We may also share billing information when it is needed to collect payment for your care.

To run our practice

We use and share your health information to run our practice, improve your care and contact you when needed. For example, we may use your records to review the quality of our care and to train our team. We may also contact you to remind you of an appointment or to follow up after treatment.

Some companies do work for us that involves your health information, such as the company that provides our practice software. They must agree in writing to protect your information and to use it only as our contract with them allows.

We are allowed or required to share your information in other ways, usually in ways that contribute to the public good, such as public health and research. We have to meet the conditions in the law before we can share your information for these purposes.

Substance use disorder treatment records

Some records from substance use disorder treatment programs have extra protection under a federal law, 42 CFR Part 2. If we have records like these about you, we will not use or share them, or testimony about what they contain, to investigate you or bring criminal charges against you, or in any civil, criminal, administrative or legislative proceeding against you, unless:

you give written consent, or
a court orders it after you, or the holder of the records, has had notice and a chance to be heard, as 42 CFR Part 2 provides.

Before the records are used or shared, the court order must also come with a subpoena or other legal requirement that compels us to share them. This limit applies to every use and sharing described in this notice, including for law enforcement and lawsuits.

When the law allows or requires it

Each use below is also subject to the Texas limits described under Extra protections under Texas law. Where Texas law requires your written consent, we will ask for it.

Public health and safety. We may share information to prevent or control disease, report reactions to medicines or problems with medical products, help with product recalls, and prevent or lessen a serious and imminent threat to anyone’s health or safety. Texas law requires dentists to report certain diseases to public health authorities.
Abuse, neglect or domestic violence. Texas law requires us to report suspected abuse or neglect of a child, and suspected abuse, neglect or exploitation of a person 65 or older or an adult with a disability. We may also report other suspected abuse, neglect or domestic violence to the agencies that receive these reports, when the law requires or allows it.
Research. We may use or share your information for health research only when federal and Texas law allow it, for example with the approval of a research review board and an agreement to keep your identity confidential.
Complying with the law. We share information when federal, state or local law requires it, including with the U.S. Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
Health oversight. We may share information with agencies that oversee health care, such as the Texas State Board of Dental Examiners, for audits, investigations, inspections and licensing, as the law allows.
Organ and tissue donation. We may share information with organizations that handle organ, eye or tissue donation, as the law allows.
Coroners, medical examiners and funeral directors. We may share information with a coroner or medical examiner, for example to help identify a person from dental records, and with a funeral director as needed.
Workers’ compensation. We may share information for workers’ compensation claims and similar programs, as the law allows.
Law enforcement. We may share information with law enforcement officials when the law requires it or Texas law allows it. For example, we may release dental records to help find a missing person, or respond to a grand jury subpoena or a court order.
Special government functions. We may share information for military and veterans activities, national security and intelligence, and protective services for the President and others. If you are an inmate or otherwise in custody, we may share information with the correctional institution or law enforcement official that has custody of you.
Lawsuits and legal actions. We may share information in response to a court or administrative order. We share it in response to a subpoena or other legal request only within the Texas limits described under “Dental records in court cases” below.

Uses that need your written permission

We never use or share your information for these purposes unless you give us written permission:

Marketing
Sale of your health information
Most sharing of psychotherapy notes

Any other use or sharing of your health information that this notice does not describe will happen only with your written permission. You can take back your permission at any time by telling us in writing. Taking it back does not undo anything we already did because of it.

Extra protections under Texas law

Where Texas law protects your health information more than federal law does, we follow Texas law. For example:

Your dental records are privileged. Texas law treats your dental records, and what you tell your dentist about your care, as privileged and confidential. We share them only with your written consent, or in the situations Texas law lists. These include sharing with another dentist, or someone working under a dentist’s direction, who is helping to diagnose or treat you; sharing what is needed to bill and collect payment for your care; reports another law requires us to make to a government agency that agrees to keep your identity confidential; warning medical or law enforcement personnel when we believe someone is likely to be physically hurt very soon; investigations by the Texas State Board of Dental Examiners; and audits, program reviews or research when the person receiving the records agrees to keep your identity confidential. Your written consent must say what information may be shared, with whom and why. You can take it back in writing at any time.
Dental records in court cases. In a lawsuit or other legal proceeding, we will release your dental records only with your written consent, when a court orders it, or where Texas law says the privilege does not apply. For example, it does not apply in a case you bring against us, a case to collect payment for your care, or a grand jury subpoena.
Sharing your information electronically. Texas law requires us to tell you that your health information may be shared electronically, for example when we send a claim to your dental plan or x-rays to another dentist who is treating you. Except when we share it with other health care providers, dental or health plans, or others covered by Texas privacy law for treatment, payment, running our practice or insurance purposes, or when another law allows or requires it, we will not share your health information electronically without your separate permission each time.
HIV test results. Texas law makes HIV and AIDS test results, including whether you have been tested, confidential. We share them only as Texas law allows, for example with your signed written permission that names who may receive them, with health care personnel who need them to care for you, or for public health reports the law requires.
Marketing and sale. Texas law requires your clear permission, in writing or electronically, before we use or share your health information for marketing, and it limits the sale of health information.

Your records, our license and state complaints

To get your records, ask at our front desk, call (936) 327-2151, or write to Today’s Dental, 604 N Willis Ave, Livingston, TX 77351. Tell us which records you want, whether you want paper or electronic copies, and where to send them. We may ask you to sign a written request and to show ID.
Our license. Dentists in Texas, including Dr. Guiste, are licensed by the Texas State Board of Dental Examiners. You can contact the board, or file a complaint with it, through its website at tsbde.texas.gov, by email at complaints@tsbde.texas.gov, or by mail to Texas State Board of Dental Examiners, Attn: Investigations Division, 1801 Congress Ave., Suite 8.600, Austin, TX 78701.
State privacy complaints. The Texas Attorney General’s Health Care List of Agencies, on texasattorneygeneral.gov, names the state agencies that take complaints about the privacy of health information and tells you how to reach each one.

Our responsibilities

We are required by law to keep your health information private and secure, to give you this notice of our legal duties and privacy practices, and to notify you if a breach affects your unsecured health information.
We must follow the terms of the notice currently in effect and give you a copy of it.

Changes to this notice

We can change the terms of this notice, and the changes will apply to all information we have about you, including information we had before the change. The new notice will be posted in our office and on our website, and we will give you a copy if you ask.

Contact and complaints

Contact our privacy officer

Privacy officer, Today’s Dental
604 N Willis Ave, Livingston, TX 77351
(936) 327-2151 (ask for our privacy officer)

How to file a complaint

If you believe we have violated your privacy rights, you can complain to us by calling or writing to our privacy officer.
You can also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Complaints to the Office for Civil Rights must be in writing:
- Online: www.hhs.gov/hipaa/filing-a-complaint
- By mail: Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201
- For help, call the Office for Civil Rights at 1-800-368-1019 (TDD 1-800-537-7697)
You can also complain to the State of Texas. See Your records, our license and state complaints above.
We will not retaliate against you or treat you differently for filing a complaint.

Effective date

This notice takes effect on [date to be set by counsel].

Notice of privacy practices